Terraces of Boise, the

Inspectors wroteBased on Idaho State LTC Reporting Portal System, policy review, record review and staff interview, it was determined the facility failed to ensure resident's rights were protected to be free from misappropriation of residents' funds. This was true for 1 of 3 residents (Resident #39) whose record was reviewed for misappropriation. This deficient practice caused emotional and financial harm when Resident #39's personal finances were used by a facility staff member.

Inspectors wroteBased on observation, the FDA Food Code, and staff interview, it was determined the facility failed to ensure food items were appropriately labeled, dated, and covered, dish racks and air condenser refrigerator fans were cleaned and sanitized. These deficiencies had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, record review, and staff interview it was determined the facility failed to ensure sanitary laundry services were provided to the residents, hand hygiene was performed by facility staff, and medication was stored appropriately. This deficient practice had the potential for harm if facility residents were provided laundry, staff cares, and medications which were not handled with appropriate sanitation practices.

Inspectors wroteBased on observation, policy review, and staff interview it was determined the facility failed to ensure residents were treated with dignity when referring to resident's as feeders who require assistance when eating, as well as serving meals at the same time to residents sitting at the same table. This was true for 4 of 4 residents (#3, #13, #17, and #22) who were observed during dining. This deficient practice had the potential to create psychosocial harm to residents if resident's felt inferior by being referred to as feeders or not being served meals at the same time.

Inspectors wroteBased on observation, SOM Appendix PP, and staff interviews it was determined the facility failed to provide timely meals to residents when they had to wait more than 45 minutes to receive breakfast from the posted time. This was true for 7 of 15 residents (#3, #13, #14, #17, #22, #33 and #50) observed during dining service. This deficient practice created the potential for harm if residents did not receive their meal to avoid potential food-medication interactions, and psychosocial harm if not provided meals in a timely manner.

Inspectors wroteBased on observation, staff interview, and record review, it was determined the facility failed to ensure position change alarms were assessed as potential restraints and a consent from the residents' representative and physician's order were obtained prior to installation of the alarms. This was true for 2 of 3 residents (#14 and #22) reviewed for potential restraints. This deficient practice had the potential for harm if the position change alarms were improperly used and if resident's experienced physical deterioration due to lack of movement.

Inspectors wroteBased on record review and staff and resident interview, it was determined the facility failed to ensure resident's missing personal item was investigated as potential misappropriation of resident's property. This was true for 1 of 1 resident (Resident #34) reviewed for misappropriation of personal property. This failure created the potential for Resident #34 to experience emotional distress due to the loss of a personal item with inherent value.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure resident's MDS assessments accurately reflected their status. This was true for 1 of 1 resident (Resident #6) whose MDS assessment was reviewed. This deficient practice had the potential for negative outcomes if Resident #6 was not assessed and/or monitored due to inaccurate assessments.

Inspectors wroteBased on observation, record, policy review, and staff interviews, it was determined the facility failed to follow residents comprehensive centered care plans. This was true for 1 of 6 residents (Resident #22) reviewed for care plan implementation. This deficient practice had the potential for physical harm related to Resident #22's receiving beverages that did not meet her ordered dietary needs.

Inspectors wroteBased on observation, record review, and staff interview it was determined the facility failed to ensure care plans were revised as needed. This was true for 1 of 13 residents (Resident #8) whose record was reviewed for care plan revision. This deficient practice created the potential for harm if the Resident #8 did not receive oxygen treatment as ordered.

Inspectors wroteBased on policy review, observation, and interview, it was determined the facility failed to ensure medications were administered according to professional standards of practice. This was true for 1 of 7 residents (Resident #42) observed during medication administrations. This failed practice created the potential for Resident #42 to experienced adverse effects when her medications were not administered according to physician's order.

Inspectors wroteBased on observation, record review, and staff interview it was determined the facility failed to provide respiratory services. This was true for 1 of 1 resident's (Resident #8) who was reviewed for oxygen and respiratory services. This deficient practice had the potential for Resident #8 to experience shortness of breath when her physician's order was not followed.

Inspectors wroteBased on observation, record review, staff interview, and policy review, it was determined the facility failed to ensure medications were secured when they were unattended by staff and to ensure pharmacy labels matched the physician's order. This was true for 1 of 1 resident (Resident #30) whose medication administration was observed. This failed practice created the potential for harm if medications were taken by another resident and should Resident #30's Oxycodone (opioid pain medication) be administered at the wrong dose.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure kitchen equipment was clean and food was stored in a safe and sanitary manner. This deficency had the potential to affect the 36 residents who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on observation, interview, and FDA Food Code review, it was determined the facility failed to ensure garbage was properly disposed of to minimize attracting insect and rodents. This deficient practice had the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection prevention measures were taken when reusable medical equipment was not disinfected between residents. These failures had the potential to impact residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on policy review I&A report review, record review and staff interview, it was determined the facility failed to ensure call lights were within residents' reach. This was true for 1 of 2 residents (Resident #49) reviewed for falls. This resulted in harm to Resident #49 when she fractured her left hip and left wrist.

Inspectors wroteBased on record review, and staff interview, it was determined the facility failed to ensure residents were monitored for side effects and offered non-pharmacological interventions prior to administering an opioid pain medication. This was true for 3 of 7 residents (#34, #49, and #102) reviewed for unnecessary medications. This failure created the potential for residents to experience adverse reactions due to a lack of appropriate monitoring or increased pain due to not offering non-pharmacological interventions.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents were labeled and dated; this was true for 2 of 3 medication storage rooms inspected. This failure created the potential for residents to receive medication used for another resident presenting a risk for cross-contamination or to receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure food items were dated and labeled and hygiene practices followed. This failure had the potential to affect 43 of 43 residents residing in the facility who consumed food prepared by the facility at risk of adverse health outcomes, including food-born illnesses.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure the facility's binding Arbitration Agreement was explained and understood by the resident and/or their representatives and to inform the resident and/or their representative of the 30 days to rescind the agreement if they so wished to do so. This was true for 39 of 43 residents in the facility. This had the potential for residents to make a misinformed decision when the agreement was not explained.

Inspectors wroteBased on record review, and staff interview, it was determined the facility failed to ensure the facility's binding Arbitration Agreement provided a neutral arbitrator agreed upon both parties and a venue that was convenient to both parties. This was true for 39 of 43 residents in the facility who signed the Arbitration Agreement. This failure created the potential for an unfair Arbitration process in a venue convinent to both parties.

Inspectors wroteBased on observation, policy review, record review, and resident and staff interview, it was determined the facility failed to ensure residents were treated with dignity and respect. This was true for 2 of 2 residents (#5 and #35) reviewed for respect and dignity. This deficient practice placed Resident #5 and #35 at risk of embarrassment and diminished sense of self-worth.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure abuse and neglect were thoroughly investigated. This was true for 1 of 4 residents (Resident #39) reviewed for abuse and neglect. This failure created the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on policy review, record review, review of the State Survey Agency's Long-Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure potential abuse, neglect, and mistreatment was thoroughly investigated. This was true for 1 of 4 residents (Resident #39) reviewed for investigations. This failure reacted the potential for residents to be subjected to ongoing abuse without detection and protective measures implemented by the facility.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a bed hold was provided for residents leaving the facility for a hospital stay or therapeutic leave. This was true for 1 of 1 resident (Resident #49) whose record was reviewed for hospitalization. This deficient practice created the potential for psychosocial distress if residents were not informed of their right to return to their former bed/room at the facility within a specified time.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure a controlled substance was tracked and disposed of in a timely manner. This was true for 1 of 3 medication carts observed. This failure created the potential for undetected misuse and/or diversion of a controlled medication.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure a resident was free from a medication error. This was true for 1 of 1 resident (Resident #102) whose medication record was reviewed for accuracy. This failure placed Resident #102 at risk of not receiving the correct ordered medication for constipation.